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A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds each, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction, nadir after the peak of the contraction, and a return to baseline after the contraction is over.
Which of the following actions should the nurse take?

A.

Increase the rate of infusion of the IV oxytocin.

B.

Decrease the rate of infusion of the maintenance IV solution.

C.

Discontinue the infusion of the IV oxytocin.

D.

Slow the client's rate of breathing.

E.

Slow the client's rate of breathing.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Increasing the rate of infusion of IV oxytocin in the presence of abnormal fetal heart rate decelerations is contraindicated. It may exacerbate uterine hyperstimulation, further compromising fetal oxygenation.

 

Choice B rationale

Decreasing the rate of infusion of the maintenance IV solution will not address the issue of uterine hyperstimulation or abnormal fetal heart rate decelerations. The focus should be on managing oxytocin administration.

 

Choice C rationale

Discontinuing the infusion of IV oxytocin is appropriate due to uterine tachysystole and associated fetal heart rate decelerations. This helps reduce uterine contractions and allows for fetal recovery, improving oxygenation.

 

Choice D rationale

Slowing the client's rate of breathing is not related to managing uterine contractions or fetal heart rate decelerations. The intervention should directly address the cause of the decelerations, which is oxytocin-induced hyperstimulation. .


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

The placenta does not provide thermoregulation; that function is managed by maternal thermoregulation and the amniotic fluid which insulates the fetus.

Choice B rationale

Amniotic fluid cushions the fetus from maternal movements, not the placenta. The placenta's role is more focused on nutrient and waste exchange.

Choice C rationale

The placenta facilitates metabolic functions and gas exchange, supplying oxygen and nutrients to the fetus while removing carbon dioxide and waste products, ensuring fetal development.

Choice D rationale

The placenta doesn't provide a sterile environment. This is accomplished by the amniotic sac and amniotic fluid. The placenta connects the fetus to maternal blood supply, ensuring necessary exchanges for fetal growth.

Correct Answer is C

Explanation

Choice A rationale

Clapping hands to assess hearing is not a reliable method and could startle the baby for reasons unrelated to hearing ability.

Choice B rationale

While a newborn might respond to visual stimuli, this is not a definitive method to assess hearing.

Choice C rationale

Routine hearing screenings using objective tests are the best way to determine a newborn's hearing ability, providing accurate and early detection of potential hearing issues.

Choice D rationale

This statement is misleading, as some forms of hearing loss can be inherited. It's important to use accurate methods to assess newborn hearing.

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